Incidence of pseudotumor and acute lymphocytic vasculitis associated lesion (ALVAL) reactions in metal-on-metal hip articulations: a meta-analysis.

We systematically reviewed the peer-reviewed literature to determine a pooled estimate of the incidence of pseudotumor and acute lymphocytic vasculitis associated lesions (ALVAL) in adult patients with primary metal-on-metal (MoM) total hip arthroplasty or resurfacing. Fourteen eligible articles were identified, with a total of 13,898 MoM hips. The incidence of pseudotumor/ALVAL ranged from 0% to 6.5% of hips with a mean follow-up ranging from 1.7 to 12.3 years across the studies. The pooled estimated incidence of pseudotumor/ALVAL is 0.6% (95% CI: 0.3% to 1.2%). The rate of revision for any reason ranged from 0% to 14.3% of hips, with a pooled estimate of 3.9% (95% CI: 2.7% to 5.3%).

Locked Plating versus Nailing for Proximal Tibia Fractures: A Multicenter RCT.

OBJECTIVES: The main 2 forms of treatment for extraarticular proximal tibial fractures are intramedullary nailing (IMN) and locked lateral plating (LLP). The goal of this multicenter, randomized controlled trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter, randomized controlled trial. SETTING: 16 academic trauma centers. PATIENTS/PARTICIPANTS: 108 patients were enrolled. 99 patients were followed for 12 months. 52 patients were randomized to IMN, and 47 patients were randomized to LLP. INTERVENTION: IMN or lateral locked plating. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, Bother Index, EQ-5Dindex and EQ-5DVAS. Secondary measures included alignment, operative time, range of motion, union rate, pain, walking ability, ability to manage stairs, need for ambulatory aid and number, and complications. RESULTS: Functional testing demonstrated no difference between the groups, but both groups were still significantly affected 12 months postinjury. Similarly, there was no difference in time of surgery, alignment, nonunion, pain, walking ability, ability to manage stairs, need for ambulatory support, or complications. CONCLUSIONS: Both IMN and LLP provide for similar outcomes after these fractures. Patients continue to improve over the course of the year after injury but remain impaired even 1 year later. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Suprapatellar versus infrapatellar approach for intramedullary nail fixation of tibial shaft fractures: a review of the literature.

Semi-extended suprapatellar intramedullary nail fixation of tibial fractures has recently been gaining popularity. Several recent studies and meta-analyses compare the outcomes of the suprapatellar approach with the traditional infrapatellar approach. Despite concerns with intra-articular placement of instruments, studies show the suprapatellar approach to be a safe alternative. Several articles conclude that the suprapatellar approach may be superior to the infrapatellar approach. This review discusses recent findings comparing suprapatellar and infrapatellar approaches for nail insertion.

Smith-Petersen Versus Watson-Jones Approach Does Not Affect Quality of Open Reduction of Femoral Neck Fracture.

OBJECTIVE: To compare immediate quality of open reduction of femoral neck fractures by alternative surgical approaches. DESIGN: Retrospective cohort study. SETTING: Twelve Level 1 North American trauma centers. PATIENTS: Eighty adults 18-65 years of age with isolated, displaced, OTA/AO type 31-B2 or -B3 femoral neck fractures treated with internal fixation. INTERVENTION: Thirty-two modified Smith-Petersen anterior approaches versus 48 Watson-Jones anterolateral approaches for open reduction performed by fellowship-trained orthopaedic trauma surgeons. MAIN OUTCOME: Reduction quality as assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS: No difference was observed in the rate of acceptable reduction by modified Smith-Petersen (81%) versus Watson-Jones (81%) approach (risk difference null, 95% confidence interval -17.4% to 17.4%, P = 1.00) with 90.4% panel agreement (Fleiss' weighted κ = 0.63, P < 0.01). Stratified analyses did not identify a significant difference in the rate of acceptable reduction between approaches when stratified by Pauwels angle, basicervical or transcervical fracture location, or posterior comminution. The Smith-Petersen approach afforded a better reduction when preoperative skeletal traction was not applied (RR = 1.67 [95% CI 1.10-2.52] vs. RR = 0.87 [95% CI 0.70-1.08], P = 0.006). CONCLUSIONS: No difference was observed in the quality of open reduction of displaced femoral neck fractures in young adults when a Watson-Jones anterolateral approach versus a modified Smith-Petersen anterior approach was performed by orthopaedic trauma surgeons. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

In-Hospital Morbidity and Mortality of Traumatic Lower-Extremity Amputations.

Traumatic lower-extremity amputations often result in complications and surgical revisions. The authors report the in-hospital morbidity and mortality of traumatic lower-extremity amputations at a metropolitan level I trauma center for a large rural region and compare below-knee (BK) vs higher-level amputation complications. They retrospectively reviewed 168 adult patients during a 10-year period (2005 to 2015) who had a traumatic injury to the lower extremity that required an amputation. Main outcome measurements included amputation level, complication rates, intensive care unit (ICU) admission rates, length of stay, total trips to the operating room (OR), and Injury Severity Score (ISS). A total of 95 patients had through-knee/above-knee (TK/AK) amputations, and 73 patients had BK amputations. The majority of injuries occurred in the non-urban setting. The TK/AK group had higher ICU admission rates (76% vs 35%, P<.0001), longer overall hospital length of stay (22.0 vs 15.5 days, P=.01), more total OR trips (6.5 vs 5.0, P=.04), and higher ISS (17.0 vs 11.5, P<.0001). A complication was experienced by 64% of all patients during the initial hospitalization. The TK/AK group had higher complication rates than the BK group, including wound infection, pulmonary embolus, rhabdomyolysis, compartment syndrome, and death. Patients with TK/AK traumatic amputations have a greater burden of injury with higher complication rates, increased ICU admissions, increased length of stay, and increased ISS and require more return trips to the OR compared with patients with BK amputations. [Orthopedics. 2020;43(6):e561-e566.].

Are Routine Follow-up Radiographs Necessary for Extra-articular Scapula Body Fractures Managed Conservatively?

INTRODUCTION: Extra-articular scapula body fractures have been shown to have good outcomes with nonsurgical management. What is not known is whether routine postinjury imaging of these fractures is necessary for monitoring healing and alignment. As the shift toward providing cost-effective healthcare continues, we sought to evaluate if routine postinjury imaging of these fractures resulted in any change in management while secondarily evaluating the imaging for fracture patterns at risk of displacement. METHODS: A retrospective review of all extra-articular scapula body fractures managed nonsurgically at our institution was performed from January 2013 to December 2017. We measured the glenopolar angle, lateral border offset, sagittal angulation, and translation on both injury CT scans and follow-up radiographs to evaluate if any displacement occurred. In fractures that displaced more than 10 mm or 10° in any measurement, we evaluated the fracture pattern to see if any particular pattern posed a risk for displacement. In addition, we evaluated the cost of imaging for all radiographs obtained in the follow-up period. RESULTS: A total of 139 patients with 147 extra-articular scapula body fractures were included in our analysis. No patient experienced a change in management based on postinjury radiographs. A total of 120 patients underwent postinjury imaging with a total of 204 radiographic series ordered, equating to $172,769.50 in radiograph expenses. Final radiographs were obtained at an average of 48.4 days postinjury, and overall, no significant difference was observed (P < 0.05) in any radiographic measurement when compared with the initial injury imaging; however, when looking at fractures that displaced, transverse fracture patterns of the scapula body represented a risk factor for displacement (relative risk = 6.5). DISCUSSION: Satisfactory outcomes have previously been demonstrated with nonsurgical management of scapula body fractures and for most of these injuries postinjury imaging may not be necessary or cost effective. LEVEL OF EVIDENCE: Level IV.

Open Reduction Is Associated With Greater Hazard of Early Reoperation After Internal Fixation of Displaced Femoral Neck Fractures in Adults 18-65 Years.

OBJECTIVES: To determine (1) which factors are associated with the choice to perform an open reduction and (2) by adjusting for these factors, if the choice of reduction method is associated with reoperation. DESIGN: Retrospective cohort study with radiograph and chart review. SETTING: Twelve Level 1 North American trauma centers. PATIENTS: Two hundred thirty-four adults 18-65 years of age with an isolated, displaced, OTA/AO type 31-B2 or type 31-B3 femoral neck fracture treated with internal fixation with minimum of 6-month follow-up or reoperation. Exclusion criteria were pathologic fractures, associated femoral head or shaft fractures, and primary arthroplasty. INTERVENTION: Open or closed reduction technique during internal fixation. MAIN OUTCOME: Cox proportional hazard of reoperation adjusting for propensity score for open reduction based on injury, demographic, and medical factors. Reduction quality was assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS: Median follow-up was 1.5 years. One hundred six (45%) patients underwent open reduction. Reduction quality was not significantly affected by open versus closed approach (71% vs. 69% acceptable, P = 0.378). The propensity to receive an open reduction was associated with study center; younger age; male sex; no history of injection drug use, osteoporosis, or cerebrovascular disease; transcervical fracture location; posterior fracture comminution; and surgery within 12 hours. A total of 35 (33%) versus 28 (22%) reoperations occurred after open versus closed reduction (P = 0.056). Open reduction was associated with a 2.4-fold greater propensity-adjusted hazard of reoperation (95% confidence interval 1.3-4.4, P = 0.004). A total of 35 (15%) patients underwent subsequent total hip arthroplasty or hemiarthroplasty. CONCLUSIONS: Open reduction of displaced femoral neck fractures in nonelderly adults is associated with a greater hazard of reoperation without significantly improving reduction. Prospective randomized trials are indicated to confirm a causative effect of open versus closed reduction on outcomes after femoral neck fracture. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Thromboprophylaxis an update of current practice: Can we reach a consensus?

Diagnosis, prophylaxis, and management of venous thromboembolism (VTE) in patients with fractures remain a highly controversial topic with little consensus in clinical practice or the literature. The following manuscript represents a summary of evidence presented at the 2017 OTA Annual Meeting Symposium; "Thromboprophylaxis an Update of Current Practice: Can We Reach A Consensus?" The need for prophylaxis in pelvic and acetabular fracture patients; the existing body of evidence related to VTE, pulmonary embolism (PE), and prophylaxis for patients with fractures about the knee; current evidence in Edinburgh Scotland, regarding VTE prophylaxis in patients with isolated ankle fractures and the risk of VTE in patients with a hip fracture are topics that are addressed. The reader will benefit from the wisdom of this compilation of global contributions on thromboprophylaxis.

The impact of the accreditation council for graduate medical education work-hour regulations on the surgical experience of orthopaedic surgery residents.

BACKGROUND: The advent of the eighty-hour workweek regulations generated a great deal of controversy over the potential loss of operative experience for general surgery and surgical specialty residents. We believed an investigation to review the operative experience of orthopaedic surgery residents before and after the adoption of the Accreditation Council for Graduate Medical Education duty-hour guidelines would provide important information in this debate. METHODS: The total number of surgical Current Procedural Terminology codes logged in the case-log database of the Accreditation Council for Graduate Medical Education by each second through fifth year orthopaedic resident at a single university-based program was collected from July 1, 2001, to June 30, 2005. Two groups were created from the data obtained. Group I (thirty-nine residents) included surgical codes logged for the two years prior to the implementation of the eighty-hour workweek (July 1, 2003), while Group II (forty residents) included the codes for the following two years. The average number of codes was determined for Group I and Group II. The two groups were then subdivided by postgraduate year of training. The average number of surgical codes per training year was calculated. Then the second and third year (junior) resident and fourth and fifth year (senior) resident groups were combined to create two subgroups. The mean number of surgical codes was determined for each group, and the groups were compared. RESULTS: The surgical case logs of thirty-five orthopaedic residents were reviewed during the study period. One resident left the program during the first year of the study and was excluded because of incomplete data. A total of 36,464 surgical codes were logged. The average yearly number of surgical codes per resident was 461.4. The average total number of coded procedures per resident before and after the start of the eighty-hour workweek were 455.4 and 467.3, respectively. The average yearly number of surgical codes was 432.5 for the junior residents and 491.1 for the senior residents. The average number of codes logged before and after the start of the eighty-hour workweek were 407.3 and 455.3, respectively, for the junior residents compared with 501.2 and 480.6 for the senior residents. No significant differences between the groups in any category were identified. CONCLUSION: Although many aspects of surgical training may be affected by the new work-hour restrictions, our review of the operative experience of orthopaedic surgery residents at a single institution demonstrated no significant differences before and after the implementation of the eighty-hour workweek.

Pubic symphyseal width in pediatric patients.

Traditionally, there has been no readily available and statistically sound method for evaluating the normal pubic symphyseal width in children. Normal values for the width of the pubic symphysis in the pediatric population are useful for determining pathologic widening, either congenital or posttraumatic. This investigation was directed at determining a reference range for the normal pubic symphyseal width according to age, age group, gender, and when combining these variables. Overall, the study found that the normal measurement for pediatric pubic symphyseal width ranges from 0.52 to 0.84 cm. The data also showed that the mean pubic symphyseal width for all variables combined was 0.68 cm (standard deviation of 0.16 cm and a 95% confidence interval of 0.668 to 0.690) and that anything greater than 0.84 cm needs further evaluation for pathology. The interclass correlation coefficient, test of interrater reliability, yielded moderate reliability of measurements between physicians.

Mass casualties in the Oklahoma City bombing.

The Alfred P. Murrah Federal Building in Oklahoma City was partially destroyed by a terrorist bomb on April 19, 1995. Injuries were sustained by 759 people, 168 of whom died. Fatalities occurred primarily among victims in the collapse zone of the federal building. Only 83 survivors required hospitalization. Twenty-two surviving victims sustained multiple fractures. Most victims arrived at local emergency departments by private vehicle within 2 hours. More severely injured survivors were transported by ambulance. The closer receiving hospitals used emergency department facilities and minor treatment areas. Few survivors were extricated from the bombing site more than 3 hours after the detonation. Mass casualty plans must provide for improved communications, diversion and retriage from facilities nearest the disaster site, and effective coordination of community and hospital resources.